Healthcare Provider Details

I. General information

NPI: 1689163875
Provider Name (Legal Business Name): VASCULAR ACCESS CENTERS OF ILLINOIS AT MORGAN PARK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W MONTEREY AVE
CHICAGO IL
60643-4257
US

IV. Provider business mailing address

210 S DES PLAINES ST
CHICAGO IL
60661-5500
US

V. Phone/Fax

Practice location:
  • Phone: 773-366-8035
  • Fax: 773-881-1214
Mailing address:
  • Phone: 312-654-2721
  • Fax: 866-954-5804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMITABHA MITRA
Title or Position: PRESIDENT
Credential:
Phone: 312-654-2720